Specialty registrar in public health, registered nurse and occasional aid worker.
In the practice of medicine, as in life generally, we all have a tendency to prefer simple answers to the big questions that trouble us. Did smoking cause this patient to develop lung cancer (Yes/No)? Would an aspirin a day have prevented that patient’s fatal heart attack (Y/N)? What is the Truth™? It can be hard to resist the seductive notion that there must be a single (or, at least, a primary) explanation for any significant event, however much we intellectually understand the tangled web of associations that underpin our lives. This is probably where most conspiracy theories come from – our intuitive need for non-complex answers. In some cases, where a simple answer may indeed exist, it can still be extremely hard (if not impossible) to identify. This article aims to illuminate some of the reasons for this lack of easily-accessible and/or straightforward explanations.
First let’s take an example where there almost certainly is a simple answer, just one that is completely out of our reach. A couple of months ago, while working as a health promotion specialist in Iraq, I was asked a very interesting question by one of my local colleagues: Are there more mental health problems in Iraq than there are in Britain? Good question!
Assuming that we could agree on definitions of “mental health problems” I have no doubt that there is a simple and correct answer to this question, but no realistic prospect of ever positively identifying it. I explained to him that the best we could possibly do would be to compare the reported incidence of mental health problems between the two countries, but this would still rely on two (unjustified) assumptions:
1) That Iraqi people and British people (both clinicians and patients) mean the same thing when they report mental health problems, and,
2) That Iraqi and British people are equally as likely to report these problems.
Relatively high reported levels of a particular social or medical problem do not necessarily equate to higher actual levels. For example, when comparing the levels of domestic violence reported by different police forces it is worth remembering that low levels – rather than meaning that the problem is mostly under control in those areas – can indicate a lack of awareness or engagement with the issue. Domestic violence may simply be listed as a “disturbance”, or not reported at all by forces that have not given awareness training to their officers, and the willingness of victims to come forward is likely to be proportional to how seriously the local police are known to take such reports. So, relatively low reported levels of mental illness in Iraq could be due to a lack of awareness by health professionals, inadequate service provision and cultural prohibitions against admitting to any such problem. Neither of these factors relate to whether there really is a greater prevalence of mental health problems in Iraq or the UK.
Having established that we were operating firmly within the realm of speculation, the counsellor and I moved on to discuss different kinds of mental illness, and what factors might cause them to be more or less common in different countries. For the sake of argument, I (somewhat simplistically) divided mental health problems into the categories of “illness” or “injury”. I would be happy to hear other people’s perspectives on this, but my perception is that there are some mental health problems that are caused by the mind’s relationship with the body, and others that are caused by the mind’s relationship with the outside world. No doubt there is also significant overlap between these two categories. Nevertheless, organic mental illness – which exists independently of any traumatic events that might have occurred to a person – is an acknowledged subset of psychology, and I would not be surprised to learn that levels of this type of mental health problem are pretty much the same all across the world. Taking it as a working assumption that they are, we moved on to discuss the “injury” category, or what we might call externally-induced mental illness.
The mental health teams I worked with in Iraq were seeing many cases of depression and anxiety stemming from traumatic life events. The horrific human cruelties associated with armed conflict are a well-known cause of mental health problems, but we are not all alike in our capacities to overcome the negative psychological effects that such events can have on us. The counsellor suggested that some of his clients must be suffering from organic mental illness since there was no clear triggering factor for the onset of their problem. I suspect that this is too easy a criterion for determining the origin of a mental health problem, because I can easily imagine a straw-that-broke-the-camel’s-back accumulation of psychological injury (especially in a country where people have been living in fear for a very long time). The immediately-precipitating factor for a breakdown in such a scenario could be something relatively insignificant. I explained that I also had some personal experience of delayed psychological reaction to a traumatic life event, so I would argue that mental health problems with no obvious or imminent external trigger do not have to be organic in nature.
The far higher incidence of traumatic events in the lives of people living in a war zone is one reason to suspect that there might be more mental health problems in Iraq than there are in Britain. There is no doubt that the lack of functional mental health services across the country and cultural taboos against admitting to any such issue will artificially lower Iraqi levels of reported mental health problems, but is it also possible that British levels might be artificially high?
Do we over-diagnose mental health problems in the UK? Or is there an “affluenza” effect which makes the citizens of a peaceful prosperous country more likely to experience dissatisfaction with their lives which, in the presence of a relatively large and sometimes commercially-driven mental health sector, might end up being diagnosed as depression? I can practically feel my psychologist friends bristling at the suggestion, and generally I think that they’d be right to do so. While there may be a small supply-induced-demand effect in British mental health circles, overall it seems to me that there is still a huge deficit in awareness, respect, diagnosis and support provided to people who suffer from mental health problems in the UK. I think the situation is very much worse in Iraq, but that fact shouldn’t be used to minimise the needs of anyone else by comparison.
However, the take-home message that I tried to convey to my colleague was that there was just no reliable way to make the comparison. Cross-cultural conversations about mental health problems always run up against the fact that not everyone thinks about these issues the same way. For example, some of our Iraqi patients would consider that possession by “djinns” (spirits) or the magical curses of malevolent neighbours were the best explanations for mental health problems, insofar as they acknowledge them at all. In such a social context, even assuming a well-functioning mental health infrastructure, accurate reporting is going to be hard to achieve.
Thinking about cultural attitudes, I was reminded of a story told to me by a psychologist who had worked for a long time in Cambodia. He was very interested in different interpretations of mental illness and took the radical step of discussing these issues with his Cambodian medical colleagues, rather than assuming that Western definitions would apply everywhere. He related to me a discussion about depression they had, and when he described the symptoms he was told that yes, they recognized this problem. In fact, they’d had a patient in their hospital recently who exhibited them all – a paddy rice farmer who had lost both his legs after treading on a landmine leftover from the Khmer Rouge conflict. This man had recovered very slowly, experiencing a lot more pain than they expected, had no energy, had many dark thoughts, had no hope for the future and cried very often. Even with good prostheses his livelihood was gone, because he would never again be able to spend hours up to his knees in water as he previously had done when tending and harvesting his crops. The psychologist had asked the Cambodian doctors what treatment they prescribed for the man’s symptoms. They answered, “We gave him a cow”. While he could not be a paddy rice farmer anymore, he could be a dairy farmer, and they reported that the treatment was extremely successful. “The cow was both anti-depressant and analgesic”, they said.
I love this story, and it is a useful reminder of how drug-dependent Western medicine can sometimes be. Would it have been better to give this man Prozac – creating a potentially expensive dependency without addressing the root cause of his problem? There is no doubt that some clinicians neglect practical non-pharmaceutical remedies to medical and/or psychological problems in favour of the easier option of reaching for the prescription pad. The rise of social prescribing (exercise programmes, reducing social isolation, etc.) by GPs in the UK is a very welcome trend.
As a contrast to the simple-yet-unobtainable answer of relative mental health prevalence, another incident from my time in Iraq illustrates the pitfalls of seeking simple answers where only complex ones exist. I had noticed while running health education sessions that most people were generally well informed about the symptoms of familiar diseases but had only very muddled ideas (from my perspective) about their root causes. I suppose that there are some fairly basic observational reasons for this, in that the symptoms of a disease are clear for all to see, whereas the causes can often only be inferred (and often wrongly) from the temporal sequence of events. The most common logical mistake here is known in Latin as Post Hoc Ergo Propter Hoc (or the “Post Hoc fallacy”), which roughly translates as “after this therefore because of this”. If event A is followed closely by event B then we are quite likely to assume that event B was caused by event A, when this may not be the case.
For example, one colleague told me about a man who became diabetic because he fell off a roof. This seemed somewhat unlikely to me, so I asked a few more questions. Apparently the gentleman had the accident described and was taken to hospital for treatment of his broken leg, where in the course of some routine admission tests it was identified that he was diabetic. This led us into a deep discussion of the difference between diagnosis and onset, with me floating the idea that the man had probably been diabetic for some time before he fell off the roof, and that this was just not identified before he happened to be in hospital for an unrelated reason. I am not sure that everyone found this suggestion convincing. After all, how could he have been diabetic before a doctor said that he was? Ergo, the fall must have caused it.
This sort of error is much easier to make with insidious diseases such as diabetes (we would be unlikely to find much room for disagreement about the cause of his broken leg, for example), and is obviously more likely to occur in a context of limited scientific education.
However, I would argue that it can also be traced back to the idea that there must be a simple answer – a clear and straightforward “truth”, instead of the unsatisfying mess of interwoven influences and associations that we usually find when we dig a little deeper.
Lest it appear that I am unfairly focusing on my Iraqi friends and colleagues as being susceptible to this kind of thinking, I should say that I have also frequently encountered it in the UK as well. Tutoring on a public health course for medical students, I once presented two different sources of mortality data, both useful in some ways and flawed in others, only to be met with the irritated response, “So what is the right answer? Which one should we use?”. The right answer is that there may not always be a right answer. In that case the point of the exercise was to help students to understand that any method of obtaining data has its strengths and weaknesses. The important thing is to be able to justify the choice that you make based upon those strengths and weaknesses, but our brains drive us (and, perhaps, our early schooling conditions us) to expect there to be a single, simple answer to any question posed.
I am not writing with the aim of spreading confusion, or to discourage people from seeking answers. There are many scientifically verified facts in medicine, but we have to be extremely careful about how we interpret them. For example, it is an established fact that smoking increases the risk of cardiovascular disease and various cancers. Does that mean that an individual person with lung cancer got it because she smoked? Well, no. Not necessarily. Does it mean that a particular non-smoker will never develop lung cancer? Again, not necessarily. Applying population-level statistics to individuals is known as the “Ecological fallacy”, and can lead to all sorts of medical and social mistakes. Comparing different areas or time periods as if all other variables have been controlled for is another great way to arrive at the wrong conclusion, because so many other things (differences in local definitions, reporting, service availability or other external factors) could be generating the differences you see in the data.
In summary, there are some situations where a simple answer does exist, but is impossible to conclusively verify. For a non-medical example, just ponder this question - what is the global chicken population at this precise moment? There must be an exact numerical answer, just one that we will never be able to nail down, because by the time we’d finished counting all the world’s chickens the true total would have changed significantly. In other situations there is no simple answer, but our psychology still seems non-optimally calibrated to expect one. This is an impulse that medical professionals should try to resist, especially when helping their patients to develop a helpful understanding of disease causation and accurate expectations of treatment outcomes. To paraphrase Indiana Jones (who was talking about archaeology, but whatever) in The Last Crusade, “[Medicine] is the search for fact, not truth. If it's truth you're interested in, Dr Tyree's Philosophy class is right down the hall”. Having once done that degree myself I feel I ought to add the caveat that you really shouldn’t expect simple answers in a Philosophy class either.
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